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Spine J. 2019 Sep 2. pii: S1529-9430(19)30960-X. doi: 10.1016/j.spinee.2019.08.014. [Epub ahead of print]

Opioid-Limiting Legislation Associated with Decreased 30-Day Opioid Utilization Following Anterior Cervical Decompression and Fusion.

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Department of Orthopaedics, Warren Alpert Medical School of Brown University. Electronic address:
Department of Orthopaedics, Warren Alpert Medical School of Brown University.
Warren Alpert Medical School of Brown University.



Since 2016, 35 of 50 U.S. states have passed opioid-limiting laws. The impact on postoperative opioid prescribing and secondary outcomes following ACDF remains unknown.


To evaluate the effect of opioid-limiting regulations on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions, and reoperations following elective anterior cervical discectomy and fusion (ACDF).


Retrospective review of prospectively-collected data PATIENT SAMPLE: 211 patients (101 pre-law, 110 post-law) undergoing primary elective 1-3 level ACDF during specified pre-law (December 1st, 2015 - June 30th, 2016) and post-law (June 1st, 2017 to December 31st, 2017) study periods were evaluated.


Demographic, medical, surgical, clinical and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) filled were compared at 30-day postoperative intervals, before and after stratification by preoperative opioid-tolerance. Thirty- and 90-day ED visit, readmission, and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated.


Demographic, medical, and surgical factors were similar pre-law versus post-law (all p>0.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 vs. 62.08 pills, p<.001; 202.23 vs. 549.18 MMEs, p<.001) and in their first 30 postoperative days (cumulative 30-day MMEs 444.14 vs. 877.87, p<.001). Furthermore, post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 vs. 632.20 MMEs, p<.001) and opioid-tolerant (730.08 vs. 1,122.90 MMEs, p=0.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period, preoperative opioid exposure, preoperative benzodiazepine exposure, and number of levels fused (all p<.05). Chronic (>90 day) opioid requirements were associated with preoperative opioid exposure (OR 4.42, p<.001) but not with pre/post-law status (p>0.05). Pre- and post-law patients were similar in terms of 30- or 90-day ED visits, unplanned readmissions, and reoperations (all p>0.05).


Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain.


ACDF; anterior cervical discectomy and fusion; cervical; diversion; law; legislation; narcotic; neurosurgery; opioid; orthopaedic; outcomes; predictors; readmission; risk factors; spine

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